Correctional officers, the front line custodial staff who interact on a daily basis with prisoners, have a difficult job in the best of circumstances. Working in insufficient numbers, they are asked to exercise power over and maintain control of prisoners crowded into facilities that are often no more than warehouses, devoid of opportunities to keep their inhabitants productively and peacefully engaged. The difficulties and frustrations of work as a correctional officer are compounded when prisoners have mental illness. The at times aggressive, bizarre, or repellent behavior of mentally ill prisoners can try the patience of anyone, even mental health professionals. But few correctional officers have the training in and understanding of the nature of mental illness that would help them cope better with the challenges posed by offenders with severe illnesses. They come to their jobs with the fears and prejudices of the general population towards the mentally ill. The correctional culture of order, obedience, and discipline in which they were trained leaves them further ill-prepared for handling prisoners whose behavior is either chronically or episodically ruled by their mental illness.

Correctional staff experience prisoners at close quarter twenty-four hours a day. They come to know patterns of prisoner behavior and can detect changes in them sometimes better, if not more rapidly, than mental health staff whose interactions with prisoners may be more sporadic. In most prisons, mental health staff do not regularly monitor the mental health condition of prisoners who are not on the mental health caseload either because they were not identified as ill during the initial prison in-take screening process or because they developed mental illness or emotional crises while imprisoned. Since correctional officers have the most contact with prisoners, they can notice unusual behavior or changes that may signal a mental disorder.

Correctional officers are in a position to notice if a prisoner has suddenly become extremely withdrawn and incommunicative or if one has started to act bizarrely. They are the source of many referrals to mental health staff of prisoners, alerting mental health staff of a prisoner’s need for attention. They have the opportunity to develop a relationship with them, and if a prisoner begins acting out, they can talk to the prisoner and help calm them down. On evenings and weekends there may be no mental health professionals present at all in the prison. Correctional officers find themselves in situations in which they must assess a prisoner’s conduct and make judgment calls about whether mental health professionals should be summoned; whether to remove a prisoner from his or her cell and into an observation cell or mental health unit; whether prisoners are merely acting out for attention, or whether they are in need of an immediate mental health intervention.

Understanding the nature and symptoms of mental illness enhances the ability of correctional officers to respond appropriately to mentally ill prisoners, an ability which has become increasingly important as the number of prisoners with mental illness has grown. If correctional officers view acting out as volitional, deliberate misbehavior, if they do not realize a prisoner who is mumbling to himself is hallucinating, if they don’t realize that huddling in the corner of a cell may be a sign of crippling depression, they will not call for mental health staff.

For example, a team of experts who reviewed a series of issues relating to psychiatric services in Massachusetts prisons, found that officers were under-referring prisoners for medical services. Officers had a threshold for referrals that precluded attention for many prisoners. “Correctional officers informed us that if an inmate develops a serious mental disorder, it is not likely to result in officers’ requests for mental health attention to the inmate as long as the inmate is clean, quiet, and obedient. “Bizarre behavior” is not likely to result in a referral as long as it is not disruptive.”243 In the case of John Salvi, an prisoner who was not on the mental health caseload at the time he committed suicide, the evaluation team found there was substantial evidence that Salvi “was suffering from serious thought disorder and manifested some unusual behaviors…but he did not attract enough attention to reach the relatively high threshold that staff typically use as signals for mental health services referrals.” The evaluation team also noted that “[a]ll of the correctional officers we interviewed felt that they did not have enough training in recognizing mental illness in inmates and in making decisions about referring inmates for mental health services.”244

Training for correctional officers in mental health issues can also help overcome a common assumption that security staff and mental health staff are worlds apart in views, concerns, and methods of handling prisoners. Stereotypes also impede collaboration between custodial and mental health staff. Correctional officers often believe mental health professionals coddle their patients, are duped by manipulative prisoners, and don’t sufficiently appreciate security needs. Mental health professionals may view correctional officers as blind to anything but regimentation, control, and punishment. Better mental health training for correctional officers and more collaboration between custodial and mental health staff could overcome such stereotypes and redound to the benefit of the mentally ill offenders under the control and supervision of both.

Correctional and mental health professionals interviewed by Human Rights Watch agreed on the importance of mental health training for correctional officers. They pointed out that training on the signs of and nature of mental illness will not only enable correctional officers to better respond to problems that emerge with prisoners, but that it will also enable them to better assist mental health staff. “They need more training to give a better idea of how to identify and deal with individuals with mental health issues,” Warden Gloria Henry, of California’s Valley State Prison for Women told Human Rights Watch. “When you’re trained in security, to have people comply with rules and regulations, that’s what your expectations are. When you’re dealing with people with mental health problems, you need to know how to approach them.”245

Nevertheless, such training is sorely lacking.In 2001, according to a survey by the National Institute of Corrections, forty states claimed to provide some mental health training to correctional officers, but mostly the training was minimal. Ten prison systems claimed to include roughly four hours of mental health classes in their basic training package for new correctional officers, thirteen admitted to providing fewer than four hours, and only seven stated that they provided more than four hours of training.246

In Texas, in connection with litigation about inadequate treatment of mentally ill prisoners, the Texas Department of Criminal Justice (TDCJ) markedly increased mental health training for correctional officers. In December 2001, the TDCJ noted that the department was providing, “increased training in the recognition of and the appropriate referral of the psychotic as well as potentially suicidal patient.”247 It also noted:

A concerted effort was made to provide 20 hours of specialized training for all on-hand correctional staff statewide over the last two years. In addition, the pre-service training curriculum has been revised and incorporates an extensive block of training related to mental health issues. This training has included descriptions of the most common types of psychiatric symptoms, including symptoms associated with psychotic disorders…. The training includes specific reinforcement to the policies and practices governing the placement and monitoring of offenders in segregated status. Correctional staff are instructed to inform the mental health staff of any segregated offender who exhibits symptoms of mental illness. Emphasis is placed on the role that correctional officers can play in identifying offenders who are at risk of deterioration in mental status and managing offenders with mental health needs.248

We were not able to ascertain the extent of annual follow-up, or mental health in-service training for correctional officers. The National Institute of Corrections (NIC) report found that a total of forty hours of annual mandated in-service training for correctional officers was the norm.249 But the report did not provide a breakdown on the content of the in-service training and to what extent it includes mental health components.250

A 1999 report commissioned by the California Commission on Correctional Peace Officer Standards and Training reviewed in-service training in a number of states. According to the report, California provides a three-hour course on “unusual inmate behavior.” No other state reported a similar course. Ohio and Tennessee each offered a course, lasting two and three hours, respectively, titled “managing manipulative inmate behavior.” Arizona, Nebraska, and Nevada provided officers with a course titled “con games.” Tennessee offered a three and a half-hour course in “psychological testing.” Under courses on health and welfare, only eight states — Arizona, Georgia, Hawaii, Michigan, New Mexico, Ohio, Pennsylvania, and Utah — offered courses specifically on “mental health issues/special needs inmates.” While Michigan claimed to offer a rather extensive sixteen hours of training in this area, the others ranged from between one hour and forty-five minutes to six hours.251 “We have not had a good success rate in training correctional officers. We don’t have a formal training program to raise sensitivity,” Harbans Deol, medical director for the Iowa Department of Corrections, told Human Rights Watch.252

The Colorado Department of Corrections claims that it provides correctional officers with an eight-hour in-service course on mental health issues. Qualifications necessary for teaching this course are, however, limited. “Instructors for this course should be knowledgeable about human behavior and have good communication skill,” the October 2001 instructor’s guide advised.253

Providing adequate training in mental health issues to correctional staff is complicated by the educational level of most correctional officers. According to the National Commission on Correctional Healthcare (NCCHC), most correctional officers lack a university education. “Nationally, the level of a correctional officer’s education is high school,” Harbans Deol told Human Rights Watch. “That creates a problem: how do you educate these people medically?”254

Few states provide formal additional training to guards volunteering to work in mental health units within the prisons. In responses to a National Institute of Corrections survey, only Delaware, the District of Columbia, Louisiana, New Hampshire, New Jersey, New York, Ohio, and Oregon reported that they provided special training to guards on these units.255 Nevertheless, in some prisons or units that have a special therapeutic mandate of trying to treat and rehabilitate mentally ill offenders, correctional staff do work more closely with mental health staff and receive more training. The Washington Department of Corrections developed a “mobile consultation team” to help the system deal with prisoners who are particularly difficult and disruptive. Team members include not only mental health professionals, but experienced corrections officers. The team works with prison staff who have requested consultation and together they engage in joint problem solving.256 Professor Hans Toch praises innovative programs that:

provide officers with noncustodial human-service responsibilities that resemble those of traditional mental health professionals. At the same time, the programs create a collegial relationship among the officers and mental health workers who are attached to the programs. The staff of innovative programs come to function as inclusive interdisciplinary teams.257

Toch argues strongly, and in our judgment cogently, for mental health training for correctional officers that goes beyond “a diluted psychology-101-type lecture format.” Instead, he believes officers should receive hands-on training that presents officers with real symptoms being experienced by real prisoners in the prisons in which the officers work and that integrates those officers into the mental health teams and case conferences in which prisoners’ mental health needs are discussed.258

Dangerous situations can and do arise in prisons in which the use of force may become necessary to protect staff, prisoners, or property from injury and to maintain or reestablish control. The type and extent of force used, however, should always be proportionate to the need, and force should never be used as punishment or reprisal against a prisoner. The Eighth Amendment of the U.S. Constitution is violated when force is maliciously and sadistically used against a prisoner to cause harm, rather than in a good faith effort to maintain and restore discipline.259 In addition, the constitution prohibits officials from using force that is greater, in amount or kind, than what is needed to maintain or restore order, or when force is used without any legitimate penological purpose.

International standards mandate that “officers who have recourse to force must use no more than is strictly necessary.”260 Instruments of restraint, such as four-point restraints (a process in which the prisoner is fastened to his or her bed by the feet and wrists) or strait jackets, should only be used on medical grounds by direction of a medical officer, or by order of the prison director “if other methods of control fail, in order to prevent a prisoner from injuring himself or others or from damaging property; in such instances the directors shall at once consult the medical officer.”261 The American Correctional Association’s “use of force” policy calls on correctional authorities to seek to reduce or prevent the necessity of the use of force, to authorize force only when no reasonable alternative is possible, to permit only the minimum force necessary, and to prohibit the use of force as a retaliatory or disciplinary measure. It emphasizes the importance of operating procedures and staff training to “anticipate, stabilize, and diffuse situations that might give rise to conflict, confrontation, and violence”; and the provision of “specialized training to ensure competency in all methods of use of force, especially in methods and equipment requiring special knowledge and skills such as defensive tactics, weapons, restraints and chemical agents….”262

There are no national statistics on the use of force by staff against prisoners, nor independent research assessing how well use of force practice in any given state correctional system conforms to appropriate standards. Information about use of force typically becomes public in the context of criminal prosecutions or civil litigation addressing staff abuse of prisoners that resulted in serious injuries. Human Rights Watch was unable to determine whether mentally ill prisoners are more likely to be in situations involving use of force by staff than other prisoners or whether the force used against mentally ill prisoners is more likely to be excessive than in situations involving prisoners who are not mentally ill.

Nevertheless, some correctional experts believe that correctional officers may be too quick to resort to force and to use excessive force particularly when dealing with mentally ill prisoners. Lacking adequate training in mental illness and in conflict de-escalation, often also poorly trained in the use of force in general, their efforts to control mentally ill prisoners have led, in some cases, to prisoner deaths or other serious injuries. In the past five years, Steve Martin, a well known corrections consultant and use of force expert, has investigated over twenty cases of sudden in-custody death and numerous others of serious injuries, the majority of which involved prisoners with mental health histories. Martin describes a pattern of escalating force typical in these cases:

Once you’re into the actual application of force, you have a “death escalation cycle.” As the inmate is subject to a greater level of force, he develops a greater level of anxiety, his resistance escalates accordingly, which in turns requires a greater escalation of force.263

According to Martin, the strange, often violent, and irrational behavior of agitated mentally ill prisoners, and their protracted struggling against being restrained, can scare correctional officers into acting more aggressively than they should during a restraining process. “What is very evident in these cases is the officers are simply frightened of the detainee. You can see [on the videotapes of the incidents] they perceive the detainee as an utter immediate threat to their physical well-being. It’s a dynamic created almost from the get-go.” In one jail Martin recently investigated, the name of which he is prevented from revealing by the terms of his contract, he investigated ninety-three cases of force used against mentally ill prisoners in a twelve-month period. “I’d estimate half of these could have been avoided altogether if you’d had some health care intervention,” Martin stated.

Martin told Human Rights Watch of an event that occurred in the Los Angeles County Jail in 1999. A man, G.M., with a long history of chronic mental illnesses, who was also wheelchair-bound as a result of having cerebral palsy, was brought into the jail. He was homeless and hungry; and a jail official at some point decided to give him a sandwich. Shortly afterwards, another correctional officer decided to take the sandwich away. The action enraged G.M., who jerked his arm backwards and struggled to keep a hold on his food. This was seen as him resisting an officer and several other guards immediately joined the fray, subdued the prisoner (who was still in his wheelchair), and rushed him off to a room where he could be restrained. “Three-to-five minutes into the event, he expired,” Martin told Human Rights Watch. Not only were no mental health personnel present to explain to G.M. why his sandwich was being confiscated, no mental health staff were present to advise the security officials during the restraint itself. Instead of calling in the mental health team, guards converged on the man’s wheelchair and began aggressively restraining him. Martin’s investigation found that G.M. was manhandled out of his wheelchair and placed face up on a bed. Several correctional officers jumped on top of him to begin attaching the restraints; only after the restraints were in place and the officers got off of G.M.’s body did they realize that he had stopped breathing. The subsequent medical examiner’s report found that G.M. had suffocated after his airwaves were restricted by the weight of the guards atop his body. Martin told Human Rights Watch that G.M.:

died from a classic case of positional asphyxia. A mental health team could have intervened by saying it was inappropriate to place him in four-point restraints. There should have been a mental health professional there, on-site, when they were bringing him in, in a wheelchair, to where they were going to restrain him. The security personnel really had no knowledge of this guy’s history. They weren’t even aware he had cerebral palsy.264

Martin reported several other cases of mentally ill prisoners involved in altercations with correctional officers who restrained them and the prisoners died from positional asphyxiation, which is caused by an inability to breathe because of being placed in a prone position, with the arms behind the back, making it impossible for the respiratory muscles to work properly. The inability to breathe is aggravated, and a fatal outcome is likely, when the prisoner is overweight or obese and when one or more officers kneel, sit, or stand on him. For example, an overweight prisoner with a history of chronic mental illness, was acting out in his cell, yelling, and carrying on. He reacted violently when a group of officers tried to remove him from his cell. One of the officers then sprayed the prisoner with O.C. pepper gas in his face, which made the prisoner even more agitated. The officers ultimately got him down on his stomach and restrained him. He died of asphyxiation.265

In the case of Larry Frazier, a combination of mental illness, physical illness, and excessive use of force by prison staff proved a lethal cocktail. Frazier, a fifty-year-old diabetic and schizophrenic was moved from Connecticut to Virginia’s Wallens Ridge prison as a part of a prison space leasing deal. At Wallens Ridge, Frazier went into diabetic shock, and began convulsing. He struggled with corrections officers and was stunned several times with an Ulton II stun gun, which delivers fifty thousand volts of electricity as correctional officers restrained him to a gurney. Frazier went into a coma and died five days later of heart failure.266 A doctor brought in to investigate his death concluded the use of the stun gun may have contributed to Frazier’s fatal heart attack. The lawyer representing Frazier’s estate in a suit against the Virginia Department of Corrections told Human Rights Watch he believes it possible that because of Frazier’s mental illness he had an antagonistic relationship with the guards and they therefore were more ready to assume he was disobeying their orders when he did not follow their orders to stop moving.267

In Nevada’s Ely prison in November 2002, according to a written statement by prisoners who witnessed the incident, P.T., a mentally ill prisoner on psychotropic medications, was shot in the groin by guards after they ordered him to stop talking with another prisoner and he refused. According to the statement:

One of the officers grabbed him to restrain him, [P.T.] evaded their attempts and shrugged off their efforts, and was trying to get away from them. One guard tripped over his own feet and fell as [P.T.] was successful in evading them. At this point a warning shot was fired…. After the first shell was fired, the officers again attempted to restrain the inmate. [P.T.] again was able to shrug off their attempts without attacking them, and walked away from the guards as the second round was fired directly at the inmate’s groin area making a direct hit. The guards were then able to get him to the ground without further resistance.268

The Nevada Department of Corrections (DOC) confirmed that correctional officers shot a prisoner at Ely in November. According to Glen Wharton, the Assistant Director of Operations for the DOC, the officers used bird shot, which he called “pellets.” The officers did not shoot directly at the prisoner, but shot at the floor to lessen the impact. The prisoner was hit by the ricochet of the shot and was not seriously injured. According to Wharton, this technique is commonly used at Ely to subdue violent prisoners and causes minimal injury.269

Prisoners in Louisiana have alleged in a lawsuit that guards at the Louisiana State Penitentiary would routinely conduct cell-extractions on seriously mentally ill prisoners. The complaint stated that prisoners would be assaulted “by a number of guards wielding electric shields and batons, that lead to an inmate being jolted with currents of electricity and beaten severely.” The guards are also alleged to have used pepper spray and gas spray during these extractions.270

A number of mentally ill prisoners have died in recent years after being placed in restraining chairs. Most of the deaths occurred in jails. For example:

In 1997, Michael Valent, a mentally ill prisoner in Utah, died of blood clots after spending sixteen hours strapped nude in a restraining chair.

In 1997, a mentally ill man in a jail in Osceola County, Florida, died after being placed in a restraining chair and having his head snapped back so violently that he suffered fatal injuries to his brain stem.

In a jail in Jacksonville, Florida, in 1999 a twenty-year-old mentally ill man died, reportedly after guards choked him while he was in a restraining chair.271

“Certain correctional officers, if they don’t like you they won’t do nothing for you. This morning, I got up and got out the door at 8.15. The C.O. [correctional officer] wouldn’t let me get my meds. If you don’t follow their orders, you lose your job, get a ticket, go to Seg [administrative segregation custody]. A kid the other night was real upset, and talking about committing suicide. The C.O. just didn’t care. Finally the kid erupted, started slamming on the door. Then they handcuffed him, put him in Seg. Then they took him to the Intensive Mental Health Unit.”

Some correctional officers respond not just with professionalism, but with compassion and sensitivity to mentally ill prisoners. Some do not. Our research uncovered numerous allegations of correctional officers working with the seriously mentally ill who have taunted them, deliberately provoked them, physically mistreated them, used force maliciously against them, turned a blind eye to abuses against them by others or responded with indifference to their needs. For example:

According to a federal court, evidence presented in the long-running class action litigation against the Texas prison system, “called into question the correctional officers’ ability, and willingness, to recognize psychiatric needs. One inmate, who had a history of self-mutilation, gave unrefuted testimony that a guard provided a razor blade when the inmate threatened to self-mutilate.”273

A corrections officer allegedly told a prisoner in the mental health unit at Washington Correctional Center for Women, who had taken a razor to her arm in a failed suicide attempt, “next time do it right,” and “arteries in your neck bleed.”274

On July 13, 1998, the Washington Department of Corrections fired a correctional officer after its internal investigation established he had her perform oral sex on him on multiple occasions, and threatened to kill her if she told anyone.275

Fred Cohen,who has observed conditions in Alabama prisons in connection with ongoing litigation, told Human Rights Watch that the states’ correctional officers commonly regard seriously mentally ill prisoners as malingerers against whom they are quick to use force. He told Human Rights Watch that he encountered seriously mentally ill prisoners:

locked up in steel cages that looked like shipping containers. That’s where they were locking up discipline cases. What they took to be rebelliousness was a guy who was totally dazed…. I heard from a number of inmates that all kinds of violence was imposed. If they didn’t understand a [correctional officer] they might be pulled from a bunk, kicked around, hit with batons.276

A February 2001 class action complaint by mentally ill prisoners at Phillips State Prison in Georgia, alleges a pervasive culture of guard brutality at the prison. Lawyers for the Southern Center for Human Rights, which filed the case for the prisoners, have interviewed over two hundred prisoners. “We discovered they’ve taken 300 of the most seriously mentally ill men in the system and segregated them into Phillips,” Lisa Kung, an attorney at the Southern Center for Human Rights, told Human Rights Watch.

They were supposed to be provided with adequate mental health care and treatment. Instead, the place had become this sort of madhouse — of systemic guard brutality. There was no sense of the setting being anything close to a hospital setting. It was much worse than any other prison, because the guards considered the mental illnesses security threats. The level of brutality was above and beyond beating people up. A typical example would be you’re unhappy with your medications and can’t get a psychiatrist to come down and see you; so you bang on the doors. The guards are pissed off, so they come in, beat you up, write up a ticket and throw you in the hole. This had become a culture of brutality.277

The complaint against Phillips lists fifteen incidents which are alleged to typify the abuse at the hands of correctional officers to which mentally ill prisoners at Phillips State Prison are subjected . One of the examples is the following:

On or about May 31, 2001, Prisoner 2, who is mentally ill, spit on a counselor in the presence of a lieutenant. In response, the counselor and lieutenant both spit on Prisoner 2. The lieutenant then entered the cell, Pushed Prisoner 2 and kicked his feet out from under him, put his knee in prisoner 2’s back, grabbed his head and bashed it against the floor. After placing Prisoner 2 in handcuffs and leg shackles, the lieutenant walked Prisoner 2 through the sallyport gate. He then put Prisoner 2 in a headlock and dragged the prisoner in leg shackles on a forced run to the second gate, about 75 feet away. At the infirmary, Prisoner 2 was put in five-point restraints and shot with Haldol.278

Jason Freeman, a mentally ill prisoner at Phillips, submitted an affidavit to support plaintiffs’ motion for a preliminary injunction in which he testified that in January 2003, after his cellmate set fire to their cell, Freeman:

pounded on the door and called for help…. It took about ten minutes before the officers would open the cell door. When the officers got to our cell, they placed [both inmates] in handcuffs. There was so much smoke that I was choking. When I was coming out of the cell I slipped because there was water all over the floor [where his roommate] had flooded the cell. When I was on the floor, Officer Santos kicked me in the head until the lieutenant told him to stop. As Officer Santos escorted me down the stairs, I slipped because I was disoriented and couldn’t breathe because there was smoke all over the unit. When I tried to stand up, the officer hit me in the face, and I spit at him.279

Tamara Serwer, another attorney with the Southern Center for Human Rights working on the case, told Human Rights Watch that after the complaint was filed, a cadre of officers who had been particularly brutal were transferred. A new warden, who has a mental health background, took over at Phillips shortly before the lawsuit began and recognized, according to Serwer, that the culture at the facility needed to be changed.

An ex-prisoner, U.F., in Philadelphia told Human Rights Watch:

I’ve been suffering from mental illness for thirty years. Since I was fourteen. I had a breakdown. A blackout for eighteen months. I just snapped. I was in and out of hospitals. Always on medications. Acute schizophrenic paranoia. Post-traumatic stress. I got raped in Graterford [prison] by five guys. I was in the shower. The guards had to have seen it. It’s not the best of places. Too many people. The guards ain’t no good. They turn their heads on things. If they don’t like you, they don’t intervene, no matter what happens.280

According to an Indiana prisoner, correctional officers look on and laugh or joke when a fellow prisoner self-mutilates. “The Sergeant came back onto this range at 1.00 p.m. to collect [food] trays,” the prisoner wrote.

Officer M [name deleted] also came onto the range and I got them to look into W.’s cell and they both saw that W. had stuck the pen into his neck. They continued to pick up trays on this range and then on Six Range. Sergeant E. [name deleted] and the other Sergeant working stood and laughed at [the prisoner] and then exited the range laughing.281

Four years earlier, a different prisoner asserted how yet another prisoner, “has been beaten repeatedly by the guards here. The man obviously has some psychological problems because he defecates and rubs the feces all over his body. The guards think it is funny and continue to harass him daily.”282

In Pelican Bay State Prison, a supermax prison found by a federal court to have violated the Eighth Amendment rights of its prisoners, prisoner-guard dynamics were so poisoned in the 1990s that officers routinely resorted to violence (e.g., beatings and unnecessary as well as excessively violent cell extractions) against prisoners, including many who were mentally ill.283 In one incident, correctional officers dragged a seriously decompensating African-American prisoner, Vaughn Dortch, who had covered his body in feces, to a tub full of scalding water, dumped him into the water, and, while screaming racial epithets, promised to scrub him down until his skin turned white. The water was so hot that the skin was literally burnt off Dortch’s legs.284

A California prisoner, on medication for his mental illness, recently told Human Rights Watch that correctional officers in some of the prisons he has been in:

are not equipped to deal with people with psychiatric problems. They misinterpret when a person is sick compared to what a person is being an idiot. Sometimes I get sick and they don’t understand what is going on. They think you’re playing with them. Since you’re in general population they’ll try and provoke you. Because if they think you’re sane, they’ll think you’re just being an asshole. Then they’ll really provoke you, put you up against a wall, put you down, grab your scrotum real hard. If you do anything, they’ll mace you.285

A prisoner told Dr. Dennis Koson, who was evaluating New Jersey prison conditions for plaintiffs in C.F. v. Terhune,286 that he:

saw correctional officers taunt John Doe #81 by breaking his cigarettes after promising him a light. This made John Doe #81 angry. Several hours later, John Doe #81 hung himself…. John Doe #124 also said correction officers might skip mentally ill inmates’ meals out of spite.287

“Nothing short of some major cultural change is going to alter the situation,” Janet Schaeffer, one-time Director of Mental Health Services for the Washington Correctional Center for Women, at Purdy, subsequently Director of Outpatient Mental Health Services, and currently employed at Berk County Jail, Pennsylvania, told Human Rights Watch. “The culture views prisons as places to shut people away and to punish them.”288 As a result, Schaeffer has come to believe, the correctional officers often seemed to act as if they had carte blanche to torment their prisoners. “Mentally ill people, generally, are pretty fragile individuals. They’re more vulnerable,” Schaeffer asserted.

If [an inmate walks from her] living unit to the dining room by the same route every day and then all of a sudden they say “you can’t walk within ten feet of a building, and you’re near a building so we’re going to give you an infraction” it fucks with your soul. It really, really does. It’s crazy-making. It messes with you. Sometimes it was very painful to see women treated that way. My staff would come to me outraged by this.

243 Kenneth Appelbaum, et. al, Report on the Psychiatric Management of John Salvi in Massachusetts Department of Correction Facilities 1995-1996, submitted to the Massachusetts Department of Correction, January 31, 1997, p. 35; on file at Human Rights Watch.

262 American Correctional Association’s (ACA) public correctional policy on use of force, as published in Craig Hemmens and Eugene Atherton, Use of Force: Current Practice and Policy (American Correctional Association, 1999), pp. vi-vii. Specific standards governing the use of force in corrections are contained in the ACA’s Standards for Adult Correctional Institutions, and Standards of Adult Local Detention Facilities.

266 Frazier died on July 4, 2000. Prison officials suspended the use of the stun gun after Frazier’s autopsy. Jen McCaffrey, “Doctor: Repeated use of stun gun at prison may have led to death,” The Roanoke Times, July 26, 2003.

281 The prisoner’s letter was sent to the Alliance for the Mentally Ill, June 21, 1999. It was then forwarded to Human Rights Watch.

282 Written statement by James Wilson, April 2, 1995 (copy on file at Human Rights Watch).

283 The evidence of excessive and malicious use of force at Pelican Bay lead to a court ruling that it violated the Eighth Amendment. Madrid v.Gomez, 889 F. Supp. 1146 (N.D. California, 1995).

284 This incident was one of many examples of extreme violence perpetrated by Pelican Bay correctional officers that Judge Henderson detailed in his January 1995 opinion in the Madrid v. Gomez case. Madrid v.Gomez, 889 F. Supp. 1146 (N.D. California, 1995.)The water temperature for Dortch’s bath was estimated at 125 degrees Fahrenheit.